Validation and Documentation of Data

• data requiring validation Conditions that require data to be rechecked and validated include: Discrepancies or gaps between the subjective and objective data, Discrepancies or gaps between the client says at one time versus another time
• documenting data is another crucial part of the first step in the nursing process where the categories of information on the forms are designed to ensure that the nurse gathers pertinent information needed to meet the standards and guidelines of the specific institutions mentioned previously and to develop a plan of care for the client
• documentation promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care
• charting the common term used in the field of nursing when it comes to documentation
• narrative charting is the traditional form of charting and is a source oriented record
• problem oriented record gives focus on the problems that patients face
• soap format is usually used since it gives a quick look at the observation of each nurse as well as the nursing action on each observation
• subjective data includes the patient’s complaints or perception of the present problem sited
• objective data includes the nurse’s observation using his or her clinical eye
• assessment includes the inference made by the nurse from the two types of data. This is the part wherein the problem is stated. The nursing problem is stated in a form of nursing diagnoses using the NANDA
• plan this includes the nursing actions to be made in order to solve the stated problem. This part can be revised
• intervention this is the part wherein specific nursing actions are stated
• evaluation is the part wherein the nurse evaluates the reaction of the patient or progress of the problem being solved.
• revision is the section that states the changes made in order to further resolve the problem.
• focus charting is a type of charting that involves data, action and response category and this is a client focused charting
• sbar is a model of communication o one of the most common handover mnemonic models used in health care
• situation state concisely why you need to communicate the client data that you have assessed
• background describes the events that led up to the current situation
• assessment state the subjective and objective data you have collected
• recommendation suggest what you believe needs to be done for the client based on your assessment findings
• initial assessment form is called a nursing admission or admission database
• electronic health records is used to manage the huge volume of information required in contemporary health care
• kardex widely used, concise method of organizing and recording data about a client, making information accessible to all health professionals
• nursing discharge or referral summaries completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required
• validation is the process of confirming or verifying that the subjective and objective data the nurse have collected are reliable and accurate